Background
Following publication of the MSLT-II trial showing no survival benefit of completion lymphadenectomy (CLND) in patients with melanoma sentinel lymph node (SLN) metastases, it is expected ...that practice patterns have changed. The purpose of this study is to understand real-world practices and outcomes after publication of this landmark trial.
Patients and Methods
Patients with truncal/extremity melanoma SLN metastases diagnosed between 2013 and 2019 at four academic cancer centers were included in this retrospective cohort study. Descriptive statistics, Cox proportional hazards model, and multivariable regression were used to characterize the cohort and identify predictors of CLND, harboring non-SLN (NSLN) metastases, and survival.
Results
Results of 1176 patients undergoing SLN biopsy, 183 had SLN metastases. The number of patients who underwent CLND before versus after trial publication was 75.7.% versus 20.5% (HR 0.16, 95% CI 0.09–0.28). Of those undergoing nodal observation (NO), 92% had a first nodal-basin ultrasound, while 63% of patients had a fourth. In exploratory multivariable analyses, age ≥ 50 years was associated with lower rate of CLND (HR 0.58, 95% CI 0.36–0.92) and larger SLN deposit (> 1.0 mm) with increased rate of CLND (HR 1.87, 95% CI 1.17–3.00) in the complete cohort. Extracapsular extension was associated with increased risk of NSLN metastases (HR 12.43, 95% CI 2.48–62.31). Adjusted survival analysis demonstrated no difference in recurrence or mortality between patients treated with CLND versus NO at median 2.2-year follow-up.
Conclusion
Nodal observation was rapidly adopted into practice in patients with melanoma SLN metastases at four centers in Canada. Younger age and higher nodal burden were associated with increased use of CLND after trial publication. Ultrasound (US) surveillance decreased with time from SLNB. In our study, CLND was not associated with a decreased risk of recurrence or mortality.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
22.
Follow-up of patients with retroperitoneal sarcoma Baia, Marco; Ford, Samuel J.; Dumitra, Sinziana ...
European journal of surgical oncology,
June 2023, 2023-06-00, Volume:
49, Issue:
6
Journal Article
Peer reviewed
Retroperitoneal sarcomas (RPS) are rare malignancies that are potentially curable by complete surgical resection. A regular surveillance program is normally commenced following surgery due to the ...risk of local recurrence (LR), especially in low-intermediate grade disease, and distant metastases (DM), especially in high-grade RPS. Consensus guidelines usually advocate for more frequent imaging during the first 2–3 years and less intensive imaging over a prolonged period thereafter, reflecting the incidence pattern of LR and DM. Definitive evidence for the most effective imaging schedule has never been provided, and retrospective studies have not shown an association between follow-up intensity and survival. Improvement in the prediction of recurrence patterns has been sustained by prognostic dynamic nomograms, which are now capable of forecasting disease behaviour in each patient according to specific features. Incorporation of such tools in clinical practice may help to stratify patients and tailor ongoing surveillance to the risk of recurrence. This may help to relieve patients’ anxiety while awaiting results of surveillance investigations, and also reduce the economic and environmental burden of repeated imaging. A randomized controlled study (SARveillance Trial) is proposed to shed light on this controversial topic, allowing clinicians to harmonize the follow-up protocol of patients undergoing surgery for RPS.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract INTRODUCTION Intraductal papillary mucinous neoplasm is an increasingly recognized disease with varying premalignant potential and unclear incidence, characterized by a mucin-producing ...epithelium and dilation of the pancreatic duct. PRESENTATION OF CASE We present the first documented case of distant intestinal intraductal papillary mucinous neoplasm recurrence following total pancreatectomy for side-branch non-invasive borderline malignant intraductal papillary mucinous neoplasm. DISCUSSION We review the current literature in order to try and answer important questions regarding our ability to predict intraductal papillary mucinous neoplasm recurrence, our understanding of the potential for recurrence and what follow-up should be recommended to properly monitor recurrence after a benign, albeit borderline malignant, side-branch lesion resection. CONCLUSION Our case report confirms that the low risk classification of an intraductal papillary mucinous neoplasm lesion even after total pancreatectomy does not always predict recurrence and that definitive prognostic factors of recurrence in the setting of non-invasive disease have yet to be identified. A vigilant long-term approach to follow-up may thus be required even in low risk cases
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background
The sentinel node biopsy following neoadjuvant chemotherapy (SN FNAC) study has shown that in node-positive (N+) breast cancer, sentinel node biopsy (SNB) can be performed following ...neoadjuvant chemotherapy (NAC), with a low false negative rate (FNR = 8.4%). A secondary endpoint of the SN FNAC study was to determine whether axillary ultrasound (AxUS) could predict axillary pathological complete response (ypN0) and increase the accuracy of SNB.
Methods
The SN FNAC trial is a study of patients with biopsy-proven N+ breast cancer who underwent SNB followed by completion node dissection. All patients had AxUS following NAC and the axillary nodes were classified as either positive (AxUS+) or negative (AxUS−). AxUS was compared with the final axillary pathology results.
Results
There was no statistical difference in the baseline characteristics of patients with AxUS+ versus those with AxUS−. Overall, 82.5% (47/57) of AxUS+ patients had residual positive lymph nodes (ypN+) at surgery and 53.8% (42/78) of AxUS− patients had ypN+. Post NAC AxUS sensitivity was 52.8%, specificity 78.3%, and negative predictive value 46.2%. AxUS FNR was 47.2%, versus 8.4% for SNB. If post-NAC AxUS− was used to select patients for SNB, FNR would decrease from 8.4 to 2.7%. However, using post-NAC AxUS in addition to SNB as an indication for ALND would have led to unnecessary ALND in 7.8% of all patients.
Conclusion
AxUS is not appropriate as a standalone staging procedure, and SNB itself is sufficient to assess the axilla post NAC in patients who present with N+ breast cancer.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Abstract only
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Background: Surgical resection is the primary therapy for local and locally advanced carcinoid tumors of the appendix. The extent of surgery is largely dictated by the size of the ...tumor. Tumors >2 cm require a right hemicolectomy with associated mesenteric lymphadenectomy. What constitutes an adequate mesenteric lymphadenectomy is not known. Methods: This is a study of a contemporary cohort from NCI’s SEER database (Jan, 2004- Nov, 2012). Patients with non-metastatic appendiceal carcinoid tumors were included. Surgical extent was defined as limited (appendectomy or illeocecectomy) or extended (hemicolectomy). Primary outcome was overall survival (OS). Survival analysis was performed using the Kaplan-Meier and Cox-proportional hazards model. Results: Of the total 1,104 patients that met the inclusion criteria, 52% were female, 88% were white and majority were middle aged (40-60y) 45%. Majority of the tumors were <2 cm (49.3%) and lymph node(LN) negative 85%. Median LN retrieved were 10 (IQR 0-17). Median follow-up was 32 months (IQR 10-61). A multivariate Cox-proportional hazard model demonstrated that increasing age, tumor size > 3cm, tumor spread to contiguous organs, LN positivity and LN count <11 (HR 1.78: 95%CI 1.17-2.69; p=0.006) are associated with worse OS. Five-year overall survival increased with the number of LN retrieved (LN 1-10, 81.4%; LN >10, 85.9%, p=0.035). Stratified analysis by LN status demonstrated that LN count <11 was an independent predictor of worse OS in node negative patients (HR 2.10: 95%CI 1.25-3.53; p=0.005) but not node positive patients (p=0.65). Subset analysis by tumors size demonstrated that prognostic value of LN count <11 was only significant for tumors greater than 3 cm (HR 2.32: 95%CI 1.15-2.03; p=0.018). Conclusions: This is the largest study to date that looks at prognostic significance of LN count for appendiceal carcinoids. The number of LNs evaluated is an independent prognostic factor in pathologic node-negative, appendiceal carcinoid tumors measuring greater than 3 cm. This data supports performing a formal lymphadenectomy (>10 LN) even if no mesenteric disease is visible for adequate staging.
IMPORTANCE: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal cancers can be associated with significant complications. Randomized trials have ...demonstrated increased morbidity with liberal fluid regimens in abdominal surgery. OBJECTIVE: To investigate the association of intraoperative fluid administration and morbidity in patients undergoing CRS/HIPEC. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis of information from a prospectively collected institutional database was conducted at a National Cancer Institute–designated comprehensive cancer center. A total of 133 patients from April 15, 2009, to June 23, 2016, with primary or secondary peritoneal cancers were included. EXPOSURES: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. MAIN OUTCOMES AND MEASURES: Morbidity associated with intraoperative fluid management calculated by the comprehensive complication index, which uses a formula combining all perioperative complications and their severities into a continuous variable from 0 to 100 in each patient. RESULTS: Of the 133 patients identified, 38% and 37% had diagnoses of metastatic appendiceal and colorectal cancers, respectively. Mean age was 54 (interquartile range IQR, 47-64) years, and mean peritoneal cancer index was 13 (IQR, 7-18). Mitomycin and platinum-based chemotherapeutic agents were used in 96 (72.2%) and 37 (27.8%) of the patients, respectively. Mean intraoperative fluid (IOF) rate was 15.7 (IQR, 11.3-18.7) mL/kg/h. Mean comprehensive complication index (CCI) was 26.0 (IQR, 8.7-36.2). On multivariate analysis, age (coefficient, 0.32; 95% CI, 0.01-0.64; P = .04), IOF rate (coefficient, 0.97; 95% CI, 0.19-1.75; P = .02), and estimated blood loss (coefficient, 0.02; 95% CI, 0.01-0.03; P = .002) were independent predictors of increased CCI. In particular, patients who received greater than the mean IOF rate experienced a 43% increase in the CCI compared with patients who received less than the mean IOF rate (31.5 vs 22.0; P = .02). CONCLUSIONS AND RELEVANCE: Intraoperative fluid administration is associated with a significant increase in perioperative morbidity in patients undergoing CRS/HIPEC. Fluid administration protocols that include standardized restrictive fluid rates can potentially help to mitigate morbidity in patients undergoing CRS/HIPEC.
ABSTRACT
Background
Cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) are complex surgeries with multiple comorbidities. The Clavien–Dindo classification (CDC) is the most commonly ...used method to report surgical morbidity, but limits it to the highest-grade complication. The Comprehensive Complication Index (CCI) is a score ranging from 0 to 100, calculated using all 30-day complications and their treatment after abdominal surgery. The aim of this study is to assess the CCI’s validity in the HIPEC patient population.
Methods
A review of our institutional cytoreduction database from 2009 to 2015 was undertaken. Patient demographics, pathology, Peritoneal Carcinomatosis Index (PCI), complications and their treatments, and length of stay (LOS) were reviewed. The CCI was calculated for each patient. Linear regression was used to assess whether the CCI and CDC were predictors of LOS.
Results
Of 157 patients reviewed, 110 (70.1%) underwent HIPEC. The majority were female (77, 66.9%), and the mean age was 53.7 years. Mean PCI was 13.2 interquartile range (IQR) 7–18. Median CDC was grade 2 (IQR 0–2), and only 9.8% had CDC of grade 4 or higher. Mean CCI was 21.4, while the median was 20.9 (IQR 0–30.8). Mean LOS was 16.2 days, while the median was 11 days (IQR 8–15 days). The CCI strongly correlated with LOS with coefficient of 0.46 95% confidence interval (CI) 0.38–0.54,
p
= 0.000.
Conclusions
The CCI is an adequate tool to capture all complications and their overall burden in patients having undergone HIPEC. This study shows that the CCI can predict LOS and could be used to quantify and compare the burden of multiple complications.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Distress screening is now required for cancer center accreditation. Understanding patient and caregiver stress is critical to successful cancer care. This study examines the perceived emotional ...impact of breast cancer on both patients and partners.
From March 2011-February 2016, patients and partners undertook an electronic, 48-point distress screen during their first visit at a surgical breast clinic. Distress was measured via self-reported concerns on a five point Likert scale. Respondents were also asked about preferred interventions. The ability of the patient and partner to manage emotions was assessed in relation to education, ethnicity, fatigue, anxiety, and depression using ordered logistic regression.
Of the 665 individuals screened, 51.7%(n = 344) were patients, while 48.3%(n = 321) were partners. Patients were more distressed than partners regarding fatigue, anxiety, depression, and worrying about the future (p < 0.005). Only 19.7% of partners requested information with regards to “managing emotions” compared to 46.3% of patients. In the univariate analysis, being a partner was protective (OR 0.49 (95%CI 0.34–0.70, p < 0.000) as was holding an advanced educational degree (OR 0.36 (95%CI 0.14–0.93) p = 0.035). In the multivariate regression, having more education remained protective, while being a partner was no longer protective (OR 0.93(95%CI 0.62–1.39, p = 0.789). Financial concerns, anxiety, depression, and worrying about the future remained statistically significant. Partners asked for help less than patients (OR 0.28 (95%CI 0.17–0.48), p < 0.000).
While partners have similar concerns as patients, they do not seek information or help in managing emotions as often as do patients. Both patient and partners with less education and increased financial distress were likely to report difficulty in managing emotions. This study identifies groups who would benefit from supportive measures even in the absence of a request for help.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
BACKGROUND:Surgical resection is the primary therapy for local and locally advanced appendiceal neuroendocrine tumors. The role of mesenteric lymphadenectomy in these patients is undefined.
...OBJECTIVE:The purpose of this study was to define the role and prognostic significance of mesenteric lymphadenectomy.
DESIGN:This was a retrospective, observational study.
SETTINGS:A population-based cohort from the National Cancer Institute Surveillance, Epidemiology, and End Results registry (January 1988 to November 2013) was used.
PATIENTS:Patients with well-differentiated neuroendocrine tumors and nonmixed histologies undergoing surgical resection were included.
MAIN OUTCOME MEASURES:The risk of lymph node metastases as a function of tumor size and overall survival with respect to lymph node count and tumor size was measured. Lymph node cut-point was determined using the Contal and O’Quigely method.
RESULTS:Of the 573 patients who met the inclusion criteria, 64% were women, 79% were white, and 76% were <60 years of age. Seventy percent of the tumors were ≤2 cm, and 77% were lymph node negative. Median lymph nodes retrieved were 0 (interquartile range, 0–14). The probability of nodal metastases was 2.7% in tumors ≤1.0 cm, 31.0% in tumors 1.1 to 2.0 cm, and 64.0% in tumors >2.0 cm. The probability of a positive lymph node increased with increasing lymph node count up to 26 lymph nodes. An ideal cut-point of 12 lymph nodes was identified by statistical modeling. After adjustment in the multivariable model, the group with 12 or fewer lymph nodes examined had significantly worse overall survival (HR = 4.33 (95% CI, 1.54–12.15); p = 0.005; 5-year survival, 88% versus 96%) than the group with more than 12 lymph nodes examined.
LIMITATIONS:Analysis was limited by the variables available in the database.
CONCLUSIONS:This is the largest study to date that looks at prognostic significance of lymph node count for well-differentiated appendiceal neuroendocrine tumors. Overall survival was worse where 12 or fewer lymph nodes were identified for tumors >1 cm. See Video Abstract at http://links.lww.com/DCR/A352.
Hepatocellular carcinoma (HCC) is a major cause of orthotropic liver transplantations (OLT). However, tumor recurrence remains a concern. Our group has shown that a rising natural α-fetoprotein (AFP) ...slope (NAS) correlates with tumor characteristics. We want to assess if a rising NAS predicts tumor recurrence.
We reviewed first OLT for HCC (n=144) at our center from 1992 to 2010. Patients with less than two AFP values before treatment were excluded (n=52). A rising NAS (>0.1 μg/L/day) was found in 28 patients whereas 64 presented a stable or dropping NAS. Demographics, pre-OLT therapy, and tumor characteristics were collected. Statistical analysis was performed using ANOVA, chi-square or Fisher's test, and logistic regression for recurrence after OLT.
Demographics were similar among the recurrence (n=12) and nonrecurrence (n=80) groups. Patients who recurred received more treatment (P=0.017), had a higher number of lesions (P=0.025), a greater total tumor size (P=0.001), and a higher incidence of microvascular invasion (P=0.013). More patients exceeded the Milan criteria (75.0% vs. 31.3%, odds ratio OR 6.60, 95% confidence interval CI 1.45-4.05, P=0.008) and had a rising NAS (58.3% vs. 26.3%, OR 3.20, 95% CI 1.11-9.22, P=0.024) among the recurrence group. NAS was also a strong predictor of microvascular invasion (P=0.040). After correcting for age and sex, both a rising NAS (OR 3.98, 95% CI 1.01-15.81, P=0.039) and nonadherence to Milan criteria (OR 5.69, 95% CI 1.14-28.38, P=0.034) were strong predictors of recurrence after OLT.
The NAS is a predictor of microvascular invasion, a finding exclusive to pathology and in itself a predictor of HCC recurrence after OLT. The NAS and Milan criteria are good predictors of recurrence. These results encourage a frequent monitoring of AFP variations before OLT.
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